Using Electronic Health Record Data to Measure the Latent Tuberculosis Infection Care Cascade in Safety-Net Primary Care Clinics.

Introduction: Prevention of tuberculosis disease through diagnosis and treatment of latent tuberculosis infection is critical for achieving tuberculosis elimination in the U.S. Diagnosis and treatment of latent tuberculosis infection in safety-net primary care settings that serve patients at risk for tuberculosis may increase uptake of this prevention effort and accelerate progress toward elimination. Optimizing tuberculosis prevention in these settings requires measuring the latent tuberculosis infection care cascade (testing, diagnosis, and treatment) and identifying gaps to develop solutions to overcome barriers. We used electronic health record data to describe the latent tuberculosis infection care cascade and identify gaps among a network of safety-net primary care clinics. Methods: Electronic health record data for patients seen in the OCHIN Clinical Network, the largest network of safety-net clinics in the U.S., between 2012 and 2019 were extracted. electronic health record data were used to measure the latent tuberculosis infection care cascade: patients who met tuberculosis screening criteria on the basis of current recommendations were tested for tuberculosis infection, diagnosed with latent tuberculosis infection, and prescribed treatment for latent tuberculosis infection. Outcomes were stratified by diagnostic test and treatment regimen. Results: Among 1.9 million patients in the analytic cohort, 43.5% met tuberculosis screening criteria, but only 21.4% were tested for latent tuberculosis infection; less than half (40.4%) were tested using an interferon-gamma release assay. Among those with a valid result, 10.5% were diagnosed with latent tuberculosis infection, 29.1% of those were prescribed latent tuberculosis infection treatment, and only 33.6% were prescribed a recommended rifamycin-based regimen. Conclusions: Electronic health record data can be used to measure the latent tuberculosis infection care cascade. A large proportion of patients in this safety-net clinical network are at high risk for tuberculosis infection. Addressing identified gaps in latent tuberculosis infection testing and treatment may have a direct impact on improving tuberculosis prevention in primary care clinics and accelerate progress toward elimination.

Contraceptive Method Switching and Long-Acting Reversible Contraception Removal in U.S. Safety Net Clinics, 2016-2021.

OBJECTIVE: To describe patterns of contraceptive method switching and long-acting reversible contraception (LARC) removal in a large network of community health centers. METHODS: We conducted a retrospective cohort study using individual-level electronic health record data from 489 clinics in 20 states from 2016 to 2021. We used logistic regression models, including individual-, clinic-, and state-level covariates, to calculate adjusted odds ratios and predicted probabilities of any observed contraceptive method switching and LARC removal among those with baseline incident LARC, both over 4-year time periods. RESULTS: Among 151,786 patients with 513,753 contraceptive encounters, 22.1% switched to another method at least once over the 4-year observation period, and switching patterns were varied. In patients with baseline LARC, the adjusted predicted probability of switching was 19.0% (95% CI 18.0-20.0%) compared with patients with baseline moderately effective methods (16.2%, 95% CI 15.1-17.3%). The adjusted predicted probability of switching was highest among the youngest group (28.6%, 95% CI 25.8-31.6% in patients aged 12-14 years) and decreased in a dose-response relationship by age to 8.4% (95% CI 7.4-9.4%) among patients aged 45-49 years. Latina and Black race and ethnicity, public or no insurance, and baseline Title X clinic status were all associated with higher odds of switching at least once. Among baseline LARC users, 19.4% had a removal (to switch or discontinue) within 1 year and 30.1% within 4 years; 97.6% of clinics that provided LARC also had evidence of a removal. CONCLUSION: Community health centers provide access to method switching and LARC removal. Contraceptive switching and LARC removal are common, and clinicians should normalize switching and LARC removal among patients.

US "Safety Net" Clinics Provide Access to Effective Contraception for Adolescents and Young Women, 2017-2019.

Objectives. To describe patterns of providing moderately effective versus the most effective contraception and of providing implants versus intrauterine devices in US community health centers. Methods. We conducted a historical cohort study (2017-2019). Outcomes were woman-level receipt of most effective contraception (long-acting reversible contraception; implants and intrauterine devices) or moderately effective contraception. We used logistic regression to identify patient and clinic factors associated with providing (1) most versus moderately effective methods, and (2) implants versus intrauterine devices. We calculated adjusted probabilities for both outcomes by age group. Results. We included 199 652 events of providing contraception to 114 280 women in 410 community health centers. Adjusted probabilities were similar across age groups for moderately versus most effective methods. However, the adjusted marginal means for receiving an implant compared with an intrauterine device were highest for adolescents (15-17 years: 78.2% [95% confidence interval (CI) = 75.6%, 80.6%]; 18-19 years: 69.5% [95% CI = 66.7%, 72.3%]). Women's health specialists were more likely to provide most versus moderately effective contraception. Conclusions. Community health centers are an important access point for most effective contraception for women of all ages. Adolescents are more likely to use implants than intrauterine devices. (Am J Public Health. 2022;112(S5):S555-S562. https://doi.org/10.2105/AJPH.2022.306913).

Title X Improved Access To Most Effective And Moderately Effective Contraception In US Safety-Net Clinics, 2016-18.

Community health centers are a crucial source of health care for reproductive-age women. Some community health centers receive funding from the federal Title X program, which provides funding for family planning services for low-income women. We describe the provision of the most effective (intrauterine devices and implants) and moderately effective (short-acting hormonal methods) contraceptive methods in a large network of 384 community health center clinics across twenty states in 2016-18. Title X clinics provided more most and moderately effective contraception at all time points and for all age groups (adolescent, young adult, and adult). They provided 52 percent more of the most effective contraceptives to women at risk for pregnancy than clinics not funded by Title X. This finding was especially notable for adolescents (58 percent more). Title X clinics play a key role in access to effective contraception across the US safety net. Strengthening the Title X program should continue to be a policy priority for public health for the Biden-Harris administration.

Automating Case Reporting of Chlamydia and Gonorrhea to Public Health Authorities in Oregon Clinics.

BACKGROUND: Optimizing sexually transmitted disease (STD) reporting to state public health authorities is important to reduce incidence and manage outbreaks of STDs. Electronic laboratory reporting (ELR) is the standard through which local clinics report STDs to state public health authority. Electronic case reporting (eCR) is an alternative approach which automates transmission of case reports to public health jurisdictions using electronic health record (EHR) data. METHODS: Working with 3 community health centers in Oregon between February 3, 2020 and May 15, 2020, we piloted an automated eCR approach for gonorrhea (GC) and chlamydia (CT) from these clinics to the Oregon Health Authority. We compared the eCR approach to the existing ELR approach to determine completeness of case reporting for GC/CT. RESULTS: A total of 365 eCRs from 206 unique patients were generated. Among 154 instances where the case detection logic was satisfied for CT, 37% (54 instances) were based on the presence of a diagnosis and 63% (97 instances) were based on laboratory data. Among 232 instances where logic was satisfied for GC, 44% (102 instances) reflected a diagnosis and 56% (130 instances) reflected laboratory results. Data completeness was uniformly equal or higher for eCRs versus ELRs. CONCLUSIONS: The eCR approach was successful in identifying CT and GC cases and provided a more complete set of information to assist public health authorities when compared with ELRs. Electronic case reporting has the potential to automate and relieve staff burden on an important reporting requirement for clinical providers.

"I didn't know you could do that": A Pilot Assessment of EHR Optimization Training.

BACKGROUND: Informatics tools within electronic health records (EHRs)-for example, data rosters and clinical reminders-can help disseminate care guidelines into clinical practice. Such tools' adoption varies widely, however, possibly because many primary care providers receive minimal training in even basic EHR functions. OBJECTIVES: This mixed-methods evaluation of a pilot training program sought to identify factors to consider when providing EHR use optimization training in community health centers (CHCs) as a step toward supporting CHC providers' adoption of EHR tools. METHODS: In spring 2018, we offered 10 CHCs a 2-day, 16-hour training in EHR use optimization, provided by clinician trainers, and customized to each CHC's needs. We surveyed trainees pre- and immediately post-training and again 3 months later. We conducted post-training interviews with selected clinic staff, and conducted a focus group with the trainers, to assess satisfaction with the training, and perceptions of how it impacted subsequent EHR use. RESULTS: Six CHCs accepted and received the training; 122 clinic staff members registered to attend, and most who completed the post-training survey reported high satisfaction. Three months post-training, 80% of survey respondents said the training had changed their daily EHR use somewhat or significantly. CONCLUSION: Factors to consider when planning EHR use optimization training in CHCs include: CHCs may face barriers to taking part in such training; it may be necessary to customize training to a given clinic's needs and to different trainees' clinic roles; identifying trainees' skill level a priori would help but is challenging; in-person training may be preferable; and inclusion of a practice coach may be helpful. Additional research is needed to identify how to provide such training most effectively.

Lessons learned about the effective operationalization of champions as an implementation strategy: results from a qualitative process evaluation of a pragmatic trial.

BACKGROUND: Though the knowledge base on implementation strategies is growing, much remains unknown about how to most effectively operationalize these strategies in diverse contexts. For example, while evidence shows that champions can effectively support implementation efforts in some circumstances, little has been reported on how to operationalize this role optimally in different settings, or on the specific pathways through which champions enact change. METHODS: This is a secondary analysis of data from a pragmatic trial comparing implementation strategies supporting the adoption of guideline-concordant cardioprotective prescribing in community health centers in the USA. Quantitative data came from the community health centers' shared electronic health record; qualitative data sources included community health center staff interviews over 3 years. Using a convergent mixed-methods design, data were collected concurrently and merged for interpretation to identify factors associated with improved outcomes. Qualitative analysis was guided by the constant comparative method. As results from the quantitative and initial qualitative analyses indicated the essential role that champions played in promoting guideline-concordant prescribing, we conducted multiple immersion-crystallization cycles to better understand this finding. RESULTS: Five community health centers demonstrated statistically significant increases in guideline-concordant cardioprotective prescribing. A combination of factors appeared key to their successful practice change: (1) A clinician champion who demonstrated a sustained commitment to implementation activities and exhibited engagement, influence, credibility, and capacity; and (2) organizational support for the intervention. In contrast, the seven community health centers that did not show improved outcomes lacked a champion with the necessary characteristics, and/or organizational support. Case studies illustrate the diverse, context-specific pathways that enabled or prevented study implementers from advancing practice change. CONCLUSION: This analysis confirms the important role of champions in implementation efforts and offers insight into the context-specific mechanisms through which champions enact practice change. The results also highlight the potential impact of misaligned implementation support and key modifiable barriers and facilitators on implementation outcomes. Here, unexamined assumptions and a lack of evidence-based guidance on how best to identify and prepare effective champions led to implementation support that failed to address important barriers to intervention success. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02325531 . Registered 15 December 2014.

Evaluation of Medicaid Expansion Under the Affordable Care Act and Contraceptive Care in US Community Health Centers.

Importance: Use of effective contraception decreases unintended pregnancy. It is not known whether Medicaid expansion under the Affordable Care Act increased use of contraception for women who are underserved in the US health care safety net. Objective: To evaluate the association of Medicaid expansion under the Affordable Care Act with changes in use of contraception among patients at risk of pregnancy at US community health centers, with the hypothesis that Medicaid expansion would be associated with increases in use of the most effective contraceptive methods (long-acting reversible contraception). Design, Setting, and Participants: This was a participant-level retrospective cross-sectional study comparing receipt of contraception before (2013) vs immediately after (2014) and a longer time after (2016) Medicaid expansion. Electronic health record data from a clinical research network of community health centers across 24 states were included. The sample included all female patients ages 15 to 44 years at risk for pregnancy, with an ambulatory care visit at a participating community health center during the study period (315 clinics in expansion states and 165 clinics in nonexpansion states). Exposures: Medicaid expansion status (by state). Main Outcomes and Measures: Two National Quality Forum-endorsed contraception quality metrics, calculated annually: the proportion of women at risk of pregnancy who received (1) either a moderately effective or most effective method (hormonal and long-acting reversible contraception) methods and (2) the most effective method (long-acting reversible contraception). Results: The sample included 310 132 women from expansion states and 235 408 women from nonexpansion states. The absolute adjusted increase in use of long-acting reversible contraceptive methods was 0.58 (95% CI, 0.13-1.05) percentage points greater among women in expansion states compared with nonexpansion states in 2014 and 1.19 (95% CI, 0.41-1.96) percentage points larger in 2016. Among adolescents, the association was larger, particularly in the longer term (2014 vs 2013: absolute difference-in-difference, 0.80 [95% CI, 0.30-1.30] percentage points; 2016 vs 2013: absolute difference, 1.79 [95% CI, 0.88-2.70] percentage points). Women from expansion states who received care at a Title X clinic had the highest percentage of women receiving most effective contraceptive methods compared with non-Title X clinics and nonexpansion states. Conclusions and Relevance: In this study, Medicaid expansion was associated with an increase in use of long-acting reversible contraceptive methods among women at risk of pregnancy seeking care in the US safety net system, and gains were greatest among adolescents.